SLR - October 2017 - Christopher J. Betrus
Reference: Schepers, Tim; Backes, Manouk; Dingemans, Siem A; de Jong, Vincent M; Luitse, Jan S. K. Similar Anatomical Reduction and Lower Complication Rates with the Sinus Tarsi Approach Compared with the Extended Lateral Approach in Displaced Intra-Articular Calcaneal Fractures. J Orthop Trauma. June 2017; 31(6), 293–298.Scientific Literature Review
Reviewed By: Christopher J. Betrus, DPM
Residency Program: The Western Pennsylvania Hospital, Pittsburgh, PA
Podiatric Relevance: Displaced, intra-articular calcaneal fractures are a common, yet difficult correction to achieve for the foot and ankle surgeon. Not only is correct anatomical alignment difficult to obtain with ORIF, but wound complications, repeat hospital admissions and prolonged surgical times are all considerations faced when planning and executing the surgical repair of a difficult calcaneal fracture. Since the 1990s, an extended lateral approach has been considered the standard approach for correction of these fractures. In this study, the authors compared results between an extended lateral approach (ELA) and a less invasive approach through the sinus tarsi (STA) using 125 consecutive patients who had experienced a displaced, intra-articular Sanders type II or III calcaneal fracture.
Methods: A therapeutic level III nonrandomized retrospective study was performed using 125 consecutive fractures with a closed, displaced, intra-articular calcaneal fracture. Sanders type I, Sanders type IV and extra-articular fractures were excluded. The decision to perform ELA or STA was left to the discretion of the three treating surgeons, all of whom were experienced in both procedures. Sixty patients were included in the ELA group, and 65 patients were included in the STA group. Patient characteristics collected were age, sex, history of diabetes mellitus, nicotine use, drug abuse and ASA classification. Main outcome measurements were wound complications (minor and major), time until surgery, operative time, length of postoperative hospitalization and reduction of the posterior facet and calcaneal body. All patients were seen at two, eight, 26 and 52 weeks post operation.
Results: The STA group was noted to have a significantly lower rate of wound complications (n=4) as compared with the ELA (n=20). Of these 20 wound complications, 11 were considered major, with deep postoperative wound infection confirmed by both a positive culture and at least contiguous osteomyelitis, colonized implants or a fistula requiring implant removal, intravenous antibiotics or wound debridement. These major complications required seven hospital readmissions and 14 reoperations. The STA group had no major wound complications, hospital readmissions or reoperations. The STA group was also seen to have a shorter duration of procedure (105 minutes) when compared to the ELA (134 minutes) and a faster time to surgery (14 days compared to 18 days). There was no significant difference in postoperative calcaneal varus/valgus, Bohler’s angle or calcaneal width. Of note, the ELA group had two postoperative step-offs, while the STA group had zero.
Conclusion: A statistically significant difference was found between using the Sinus Tarsi Approach when compared with the Extended Longitudinal Approach in the treatment of Sanders type II and III displaced, intra-articular calcaneal fractures. Wound complications and operative time was significantly improved in the STA group, without sacrificing results in anatomical reduction. A limitation to this study was the short-term follow-up, without Patient-Related Outcome Measures. Even considering this, the Sinus Tarsi Approach has been shown in this, and in other studies, to likely be the superior approach for the experienced surgeon, considering the reduction in postoperative wound complications and shorter length of operative duration.